CERVICAL CANCER Educational Experience: exfoliative cytology Professor: Dr.

Martha Elva Diaz Viv eros Presented by: Maria del Carmen Cruz Balderas Bonastre Caraza Carolina Castillo S onia Figueroa Ivan Corro Cortez Quevedo Pérez Flor Azucena Christian Garay Enriq ue González Canela Maria de Lourdes Montes FEMALE GENITAL TRACT VULVA: exterior, located in the perineal region. Formed: labia majora, labia min ora, clitoris, and hymen, Bartholin glands or Skene. FEMALE GENITAL TRACT OLDER LIPS: limit the vulvar cleft. Bond angles: mons and fork. Composed: adipos e tissue, and contain sebaceous glands, sweat glands and hair. The stratified sq uamous epithelium. FEMALE GENITAL TRACT LOWER LIP: are within the above (nymphs). Vascularized tissue, lined by stratifi ed squamous epithelium similar to that lines the vagina FEMALE GENITAL TRACT Clitoris: upper region of the mouth, with great vascular erectile organ and nerv e endings. Covered by keratinized stratified squamous epithelium. FEMALE GENITAL TRACT HYMEN: membrane partially closes the vaginal opening in virgins, and where wattl es are drilled mirtiformes FEMALE GENITAL TRACT • Skene glands AND BARTOLINO: 1AS. Lead at the top of the vaginal orifice (mucus lubricant). 2nds. Flow to the sides of the vaginal orifice (mucus lubricant). W ith the clitoris are the vulvar vestibule VAGINA Canal collapsed membranous mucosa that measured 6-9 cm in length. Communicate vu lva cervix. Cover: stratified squamous epithelium, the folds formed fornices: po sterior (on the right), anterior (below the bladder) and lateral. Sensitive to h ormonal stimuli. Fornices: sampling in studies of functional cytology. UTERUS • hollow muscular organ measured 6-7 cm. long, located in the pelvic cavity, beh ind the bladder and in front of the rectum. Consisting of cervical or uterine ne ck and body • Cervical tubular structure that comes into the vagina. Portio or ectocervix, p resents an external opening to the vagina, an internal opening into the body uni ted by endocervical canal, which connects the vagina with the uterine cavity. Th is channel is lined by mucus-producing epithelium, called the endocervical epith elium. • stratified squamous epithelium of ectocervix endocervix + epithelium of the en docervix squamocolumnar = area (where start carcinomas of the cervix) • UTERINE BODY: thick muscular training, hollow, widening toward the top. Cavity (endometrial cavity) is still down with the endocervical canal and up, closed a t the bottom (fundus), communicates to the sides with the Fallopian tubes. Its c onical shape is inverted and is lined by columnar epithelium (endometrial epithe lium): mucus and glycogen.

OVARIES: reproductive gland. On either side of the uterus. They have an ovoid sh ape and size varies by age and decline in menopause. MAKING PRODUCT • Can be done: a) taking of the vagina, b) take the cervix. • It is essential in any of the following three: • 1. That the patient has not been made and implemented douching or jellies intr avaginal ovules, 24 hours earlier. • 2. not carrying out exploration maneuver pr ior to sampling. • 3. Use dry material and degreasing. • 4. Nubile or hysterectomy in patients once-aspiring to the posterior fornix or vaginal vault. • 5. Avoiding the study during the period. • 6. The spread shoul d be thin and uniform. • 7. Visualize the cervix and fornices with speculum. TOMAS DE LA VAGINA • wooden spatula type Ayre. • lateral fornix: hormonal study. • posterior fornix : detection of malignant lesions (accumulation of exfoliated cells). CERVIX MAKING • Material ectocervix: Ayre spatula with a scraping surface on the injury. • Mat erial endocervix: inserted the tip of the blade into the neck hole and turning t he spatula is scraped 360. ENDOMETRIAL TAKES • Suspected endometrial adenocarcinoma: taken as intended by aspiration, brushin g or washing. • INLET: Used to Papanicolaou pipette, place it in the opening of the cervix with the bulb compressed once placed it is left to extend the bulb. • BRUSHES: through the brush of Ayre. • INTRAUTERINE WASHING: is performed throu gh a cervical cannula to which it adapts a syringe with saline, after introducin g the liquid is drawn in and brought a suspension of endometrial material.€This material is centrifuged and the sediment was prepared smears. MORPHOLOGY OF NORMAL CELLS • HISTIOLOGÍA ectocervical and vaginal epithelium. • stratified squamous epithel ium, non-keratinized. Devoid of glands. During sexual maturity, the histological section can observe five layers of cells: • 1. Germ layer or stratum cylinder • 2. Spinous layer deep or basal layer. • 3. Stratum spinosum INTERMEDIATE SURFACE LAYER OR. • 4. Dierks INTRAEPETELIAL AREA . • 5. SURFACE OR LAYER FUNCTIONAL LAYER CYTOLOGY OF VAGINAL EPITHELIUM AND ectocervical • In the extended smear vaginal discharge can be distinguished, according to the different histological layers, three groups of cells: • - BASAL • - MIDDLE • SUPERFICIAL • This is an atrophic cellular pattern of the vaginal mucosa in childhood In the next painting, shows the cells of a Pap smear in a girl of nine years of age, which can be observed only parabasal cells, with some white blood cells or leukocytes. The cells show a lack of hormonal activity and are therefore atrophi c cells. •

This is a cellular pattern of puberty In the next painting, shows the cells of a Pap smear in a patient of 13 years of age in which we observe that most cells are intermediate, which is an indicatio n that the ovaries are already starting their hormone function. • This is a cellular pattern of estrogen phase This painting shows the cells in a Pap smear in a patient after 15 days of menst ruation. We observed the surface cells of the last layer of the mucosa due to st imulation of the hormone estrogen. • This is a cellular pattern of progesterone or luteal phase This painting shows the cells in a Pap smear in a patient at 25 days of menstrua tion. Here we can see that the mucosa has lost the superficial cell layer due to the action of luteinizing hormone or progesterone. • This is a cellular pattern of pregnancy This painting shows the cells in a Pap smear in a patient who is in the pipeline . We can see that there are only intermediate cells full of glycogen (glucose re serves). This is a cellular pattern of postpartum • This is the painting that I find the most dramatic and colorful varieties for their phones. Here are various atrophic cells by the lack of hormones. We found only two epithelial layers: the basal and parabasal. OVERVIEW Lack of access to services and treatment. cervical cancer mortality rate in North America < Developing countries of the Americas TYPES OF MALIGNANT TUMORS From the neck (85%) epidermoid / adenocarcinoma From the body (rest)

CANCER • The cytologic diagnosis of malignancy is rendered in the characters of the iso lated tumor cells. • Most of the neoplastic cells have morphological changes tha t constitute criteria of malignancy to recognize them. CRITERIA OF MALIGNANCY • 1 .- Changes in the nucleus. • 2 .- Alterations of the cytoplasm. • 3 .- diath esis of widespread, non-specific factors. ALTERATIONS OF THE NUCLEUS • Anisonucleosis .- The difference in the size of cell nuclei. • Polymorphism .The nuclei are in various ways: wide, nodules, elongated, etc.. • Hyperchromasi a, hypochromasia, polychromasia .- cellular degenerative changes are the cause o f hyperchromasia in both benign and malignant cells. • Changes in color pattern .- The normal pattern is altered chromatin repl. Colo r are grouped in dense clumps and hyperchromic. • Irregularities in the membrane folds and wrinkling nuclear.Consisten in acute, there are also variations in th e thickness of the nuclear membrane within a cell. • Nucleoli .- The discussed increase in size and number, in neoplastic cells the nucleoli are stained red. • multinucleation .- There is variation in the size,

in the number of nucleoli and chromatin pattern. • Changes in nuclear-cytoplasmi c ratio .- The nuclei of neoplastic cells are larger than those of normal cells and loss of rel. Nucleocytoplasmic. CHANGES IN THE CYTOPLASM • Pleomorphism .- There are ways disfigured by pseudopodia-like expansions in th e form of fiber, racquet, etc. • vacuolization .- The vacuoles are common and in dicate changes that are also seen in inflammatory disorders. • Variation in colo ration .- In the SCC take a very peculiar orange color. • diathesis .- This vari es depending on whether the carcinoma in situ, squamous cell carcinoma or adenoc arcinoma inavasor. • CARCINOMA IN SITU .- The diathesis is a clean swab,€hormonal image is high, th e neoplastic groups are scarce. • INVASIVE SQUAMOUS CARCINOMA .- It has well pre served and hemolyzed erythrocytes, inflammatory factors, bacterial flora .. • AD ENOCARCINOMA .- The smear has erythrocytes and hemolysis, leukopenia and flu pol ymorphonuclear cel. Normal columnar hyperplasia. • The neoplastic cells are divided into two categories: • .- differentiated cell s can recognize their epithelium of origin and sometimes the stratum to which th ey belonged. • .- undifferentiated cells are round or oval, smaller than the dif ferentiated and do not allow to recognize the tissue of precedence. • The most frequent cancer of the cervix (cervix) with 58% • The body of the ute rus with 27% • 8% of the ovary of the vulva • The 3% • Finally the vagina with t he 3% WHAT IS CC? Class common cancer in women = cancerous cells in cervical tissue. Normal ce lls: = precancerous lesions in the uterine wall They can change cancer cells ( 50% stable and benign cells) Do not show symptoms until much progress. The c ervix is the opening of the uterus, the body pear-shaped hollow where the fetus develops, and connects with the vagina grows slowly (at first) Before cancer cells: tissues undergo changes appear abnormal cells = dysplasia (Papanicolaou) After the cel. Growing cancer spreading The first is the Pap test, carried out using a piece of cotton, a brush or a small wooden spatula to gently scrape the outside of the cervix to collect cells. The patient may feel some pressure, but usually do not feel pain. Pap Test Abnormal cells = biopsy The prognosis (chance of recovery) and choice of tre atment depend on the stage of the cancer (whether it is in the cervix or has spr ead to other places) and health status general of the patient. RISK FACTORS Exposure to HPV OTHER FACTORS: Do not be screened regularly for cervical can cer. Starting sexual intercourse at an early age. Having multiple sexual par tners or sexual contact with someone who has had multiple sexual partners. Col lapse human immunodeficiency virus (HIV), which weakens the immune system, makin g women more vulnerable to infection by HPV . Have a family history of cervic al cancer. Age group (women 30-60 years of age are at higher risk and this als o increases with age. Smoking. HPV AND CERVICAL CANCER FACTS AND DATA "Overall it is estimated that each year 466 000 new cases are diagnosed cervical

cancer, each year 231 000 women die of cervical cancer. 80% of whom come from d eveloping countries - In 1990, 74 871 women diagnosed with cervical cancer in th e Americas. It is estimated that 79.7% (59 646) of them live in Latin America an d the Caribbean - In 1990, 33 535 women died of cervical cancer in the Americas. It is estimated that CC DIFFERENCE IN SITU AND INVASIVE CARCINOMA IN SITU It is called carcinoma in situ cervical abnormalities both the glandular epithel ium, which may be equal to lesions of invasive cancer, but no penetration of the atypical cells in the underlying stroma or neighbor. INVASIVE CARCINOMA There is talk of invasive carcinoma when the injury breaks or enters the underly ing stroma, either by infiltration or destruction. DIFFERENCE CARCINOMA IN SITU • Increased cellular activity associated with metaplasia or hy perplasia of the epithelium. • Distortion at its original architecture • Changes in cell size and shape • Large mitosis • These changes may involve the cervical glands, which is the penetration gland retained the name in situ until the base ment membrane break INVASIVE CARCINOMA • Disparity of cell size and abnormal nuclei • Mitosis • Diso rderly and abnormal stromal invasion by the epithelium. • The normal epithelium is composed of mature-type cells differentiated Histology CARCINOMA Carcinoma in situ • carcinoma in situ, cervix Invasive carcinoma • stromal invasion, cervix CARCINOMA IN SITU The cells of carcinoma in situ malignancy fill the criteria gi ven above, except one: the loss of the nucleocytoplasmic ratio. • The smear diat hesis is clean and the cells show a bright coloration and apparent.€CYTOLOGY • T here are two types of cells: • Small cell carcinoma from basal layer metaplasia deep and severe dyskaryosis latter correspond to the squamocolumnar the endocerv ix area where the injury is not visible • There are undifferentiated cells where the absence of cytoplasm hinders the understanding of their histological origin . INVASIVE CARCINOMA • The more differentiated cells have analogy in shape, appearance and qualities tintoreales with benign cells. • When less differentiated carcinoma is the great er the loss of cell cytoplasm to the nucleus might present naked. • The neoplast ic cells show a great variety of different size and shape: eosinophilic cytoplas m, but can be cyanophilic, its limits are well defined • In order of frequency w e can observe small cells, fibroids and racket or tadpole cells. Carcinoma in situ • High grade intraepithelial lesion: severe dysplasia (1) atypical cells suggest ive of carcinoma in situ (2) • High-grade intraepithelial lesion: carcinoma in s itu (1) marked impairment in deep cells (single file)

Invasive carcinoma • Smear of an invasive carcinoma. Exfoliated cells of a squamous cell carcinoma of the cervix. In general polygonal, of varying size and abundant cytoplasm. Val ue núcleocitoplasmática increased. Nuclei of variable size and shape, hyperchrom atic, some homogeneous and one with chromatin clumps alternating with clear spac es. Some nuclei with irregular borders Car ci noma der Epi oducci moi ion Intr This variety of carcinoma in which the cells under a microscope, they resemble t he epidermis of the skin. It is the most common tumors of the cervix (cervix). S ometimes it is also called "squamous cell carcinoma." • Cancer Cervical squamous (CECU) is responsible for approximately 500,000 new c ases per year worldwide • The appearance of squamous cell carcinoma of the cervix is preceded by squamou s intraepithelial lesions known as dysplasia, moderate, severe, and carcinoma in situ. • According to follow-up studies of patients, these lesions are the true precursors of cervical cancer. • squamous cell carcinoma in order of frequency can be observed: • a) Small cell • b) Cells fibroids • c) racquet or tadpole cells UEN CELU AS THE REDO NDEADAS PEQ • Present • Its apparent cytoplasm nuclei are large, hyperchromic deformities wi th large hyperchromatic • If not, the structure is coarse and clumped chromatin FOR THE FU SI CELU EMR O FI BRI LARES • They tend to be grouped or isolated • They are characterized by a hyperchromic nucleus, long or narrow central • The cytoplasm is extended, elongated at eithe r end, sometimes it may be blue-green. RAQ CELU UETA IN THE GARLIC ACU REN • Forms are infrequent • They originate in the cells of the third type of carcin oma in situ • Have tail, head and central nucleus is irregular • • Chromatin is rather limited Cytoplasm O Cell types Diagnostic accuracy • If you are on a smear any of these cell types, the Dx cytology may be of squam ous cell carcinoma • The cytology of squamous cell carcinoma Dx is accurate in 9 9% of cases in terms of malignancy • And in the 91.9% in terms histology Endocervical adenocarcinoma • It has its origin in the columnar epithelium of the endocervix. • The neoplast ic cells are similar to normal cells of the endocervix, but must meet the criter ia of malignancy ADENOCARCINOMA • It is a malignant tumor arising at the expense of endometrial epithelium. • Th e lesions may be early and be limited to the surface layer in very small areas ( circumscribed carcinoma, cancer in situ), then invades the endometrial surface ( diffuse carcinoma, invasive cancer).

Symptoms • Hypermenorrhoea during active sexual life. • post-menopausal bleeding in older women. • Runoff vaginal yellow or brown. • or bleeding in the form of spots • L ate pain. • Size of the uterus variable. There are 3 histological types of ADENOCARCINOMA 1. Muco-secreting Form 3. 5 papillary variety. Clear cell Mucus-secreting FORM • The glands are lined by high columnar cells, arranged in a single row with the cores located at the base and vacuoles in the cytoplasm. PAPILLARY VARIETY • These tumors may take papillary available in certain areas or throughout the t umor. CELL S CL ARA • Special shape that can be provided in the form PALIPE or glandular • Their cel ls have abundant clear cytoplasm with vacuoles • Its nucleus is large and irregu lar ADENOCARCINOMA cytology • It is important to making direct aspiration of the external orifice of the cer vix or endometrial brushing • carried out when the patient is bleeding • 85% cer tainty of diagnosis • Widespread vaginal Dx is useful in early endometrial adeno carcinoma Cytological characteristics • There are abnormalities of the nucleus and cytoplasm: Cytoplasm grouped neoplastic cells very low presence of red blood cells large mu ltiform 3. 5. 7. 9. Abnormal cell CLINICAL CLASSIFICATION AS FIGO CC • Clinical State 0. Intraepithelial carcinoma in situ. • I. localized carcinoma of the cervix. - A. microinvasive - b. otherwise. • II. Carcinoma that extends b eyond the cervix, without reaching the pelvic wall, can invade the upper two thi rds of the vagina. - A. without parametrial invasion. - B. with parametrial inva sion. • III. Carcinoma that extends to the pelvic wall or reaches the lower third of the vagina. - A. no extension to pelvic wall. - B. with extension to pelvic wall or hydronephrosis. • IV. Carcinoma that extends beyond the pelvis or has invaded the mucosa of the bl adder or rectum. - A. with invasion to adjacent organs. - B. with distant metast ases. TREATMENT BY STAGE

• Depends on the stage of the disease is found, the size of the tumor, and patie nt age, general health status and their desire for children. • CERVICAL CANCER - STAGE 0 • Cervical Cancer Stage 0 is sometimes also called c arcinoma in situ. • Treatment may be one of the following: • 1. Conization. 2. L aser surgery. 3. Loop electrosurgical excision procedure (LEEP) 4. Cryosurgery. 5. Surgery to remove the cancerous area, cervix and uterus (total abdominal hyst erectomy or vaginal hysterectomy) for women who can not or do not want children. • CERVICAL CANCER - PHASE I • Treatment may be one of the following, depending o n the depth at which tumor cells have invaded the normal tissue: • For stage IA cancer: • 1. Surgery to remove the cancer, uterus and cervix (total abdominal hy sterectomy). The ovaries can also be removed (bilateral salpingo-oophorectomy), but usually not removed in younger women. • 2. Conization. • 3. For tumors with deeper invasion (3-5 millimeters): Surgery to remove the cancer, uterus and cervix and part of the vagina (radical hystere ctomy) along with the lymph nodes in the pelvic area (lymph node dissection). • 4. Internal radiation therapy. • For stage IB cancer: • 1. Internal and external radiotherapy. 2. Radical hysterectomy and lymph node dissection. 3. Radical hys terectomy and lymph node dissection followed by radiotherapy and chemotherapy. 4 . Radiotherapy plus chemotherapy. • CERVICAL CANCER - PHASE II • Treatment may be one of the following: • Stage II A cancer: • 1. Internal and external radiation therapy. 2. Radical hysterectomy and lymph node dissection. 3. Radical hysterectomy and lymph node dissection fol lowed by radiotherapy and chemotherapy. 4. Radiotherapy plus chemotherapy. • For stage IIB cancer: 1. Internal and external radiation therapy plus chemotherapy. • CERVICAL CANCER PHASE III • Treatment may be one of the following: • 1. Intern al and external radiation therapy plus chemotherapy. • e r . CERVICAL CANCER - PHASE IV • Treatment may be one of the following: • For stag IVA cancer: 1. Internal and external radiation therapy plus chemotherapy. • Fo stage IVB cancer: 1. Radiation therapy to relieve symptoms caused by cancer. 2 Chemotherapy.

• CERVICAL CANCER - Recurrent • If the cancer has come back (recurred) in the pe lvis, treatment may be one of the following: • 1. Radiotherapy combined with che motherapy. 2. Chemotherapy to relieve symptoms caused by cancer. • If the cancer has returned outside the pelvis, the patient may decide to enter a clinical tri al of systemic chemotherapy. Normal cells Abnormal cells